Provider Demographics
NPI:1780756932
Name:FOREST RIDGE HEALTH - BREMERTON LLC
Entity type:Organization
Organization Name:FOREST RIDGE HEALTH - BREMERTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOV
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:140 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-3639
Mailing Address - Country:US
Mailing Address - Phone:360-479-4747
Mailing Address - Fax:360-377-3736
Practice Address - Street 1:140 S MARION AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-3639
Practice Address - Country:US
Practice Address - Phone:360-479-4747
Practice Address - Fax:360-377-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589Medicaid
WA505240Medicare Oscar/Certification